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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> iE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 ,i r <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> a plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ift/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ) strict. <br /> =RACT STREET ADDRESS ' �/ 0 V,D A-La k, b . CITY/TOWN ,n4c h <br /> ) ser's Name Phone 7/� <br /> atrdress d JI City <br /> )^ntractor' s Name License# L2. - Phone Ga - 7�7G <br /> e <br /> T19- CERTIFICATE OF WORKMAN'S COMIP SATION INSURANCE ON FILE WITH SJLHD? YES NO e <br /> i 1E OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIRCR PUMP REPLACEMENT 0 <br /> iTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 111MP INSTALLATION: Contractor1G ,// �„ <br /> Type of Pump �—� „�, H.P. 0".r— <br /> SP <br /> ".SUMP REPLACEMENT: []State Work Done <br /> 4P REPAIR: (SState Work Done - <br /> t'STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> thereby certify that I have prepared this application and that the work will be done in accordant <br /> v4th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> 1 filth District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that .in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. !' <br /> [..JILL CALL FOR A GROUT INSPECT N PRIO TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED TLE: DATE: <br /> W PLOT PL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'HASE I /J <br /> i 'LICATION ACCEPTED BY oY ('cv OS DATE O a7 28 <br /> IaJITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOM PHASE III FINAL INSPECTION <br /> ;PECTION BY_ DATE INSPECTION BY E_(O <br /> N IA9r De., 1977 OM <br />